NURSING DIAGNOSIS: Altered oral mucous membrane

related to:
  1. malnutrition and fluid volume deficit;
  2. infections such as candidiasis, herpes simplex, oral hairy leukoplakia, and bacterial gingivitis/periodontitis;
  3. Kaposi's sarcoma or lymphoma in the oral cavity.
Desired Outcome
The client will have a healthy oral cavity as evidenced by:
  1. absence of inflammation
  2. pink, moist, intact mucosa
  3. absence of lesions
  4. no reports of oral dryness and pain
  5. ability to swallow without discomfort.
Nursing Actions and Selected Purposes/Rationales
  1. Assess client for and report signs and symptoms of altered oral mucous membrane (e.g. inflamed and/or ulcerated oral mucosa; corrugated, white thickenings, particularly on sides of tongue; painful vesicles that ulcerate; white plaques that can easily be scraped off; cracks and fissures at corner of mouth; reddened and retracted gingivae; reports of oral dryness and pain; dysphagia; positive results of cultured specimens from oral lesions).
  2. Implement measures to prevent breakdown of the oral mucous membrane and promote healing of existing lesions:
    1. reinforce importance of and assist client with oral hygiene after meals and snacks; avoid use of products that contain lemon and glycerin and mouthwashes containing alcohol (these products have a drying and irritating effect on the oral mucous membrane)
    2. have client rinse mouth frequently with warm saline; baking soda and water; or a solution of salt, baking soda, and water
    3. use a soft bristle toothbrush or a sponge-tipped swab for oral hygiene
    4. lubricate client's lips frequently
    5. encourage client to breathe through nose rather than mouth in order to reduce mouth dryness
    6. encourage a fluid intake of at least 2500 ml/day unless contraindicated
    7. perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
    8. encourage client not to smoke or chew tobacco (smoking dries the mucosa; tobacco acts as an irritant to the oral mucosa)
    9. instruct client to avoid substances that might further irritate the oral mucosa (e.g. hot, spicy, or acidic foods/fluids)
    10. administer antimicrobial agents (e.g. clotrimazole troches, nystatin, fluconazole, itraconazole, ketoconazole, acyclovir, foscarnet, cidofovir topical gel) as ordered
    11. if periodontal disease is present, administer the following if ordered:
      1. oral antiseptic rinses (e.g. chlorhexidine gluconate [Peridex, Periogard])
      2. antimicrobial agents (e.g. metronidazole, amoxicillin-clavulanate, clindamycin)
    12. if Kaposi's sarcoma or lymphoma lesions are present in the oral cavity, prepare client for radiation therapy, chemotherapy, and/or excision of lesion(s) if planned
    13. if aphthous ulcers are present, administer the following if ordered:
      1. topical corticosteroid preparations (e.g. fluocinonide [Lidex] ointment mixed with Orabase, Decadron elixir, clobetasol [Temovate] mixed with Orabase)
      2. thalidomide
    14. if stomatitis is not controlled:
      1. increase frequency of oral hygiene
      2. if client has dentures, remove and replace only for meals.
  3. Consult appropriate health care provider (e.g. pharmacist, clinical nurse specialist, physician) if signs and symptoms of altered oral mucous membrane persist or worsen.